Acute stroke is the third leading cause of death and the leading cause of adult disability in the US. A disproportionate amount of morbidity and mortality falls on underserved populations. Reduction of health disparities has become a significant public health challenge and is a major goal of the Healthy People 2010 initiative. The programmatic goal of this proposal is to identify biological and socioeconomic factors contributing to ethnic disparities and to develop innovative approaches to reduce these disparities for ischemic and hemorrhagic stroke. Three research projects are proposed. Project 1, Acute Stroke Program of Interventions addressing Racial and Ethnic disparities (ASPIRE), is an intervention study designed to investigate whether implementation of a multilevel intervention can significantly increase the number of ischemic stroke patients appropriately treated with intravenous tissue plasminogen activator (IV tPA) in a predominantly underserved community. The primary outcome measure will be the percentage of all ischemic stroke patients appropriately treated with IV tPA. Project 2, Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia (PROTECT DC) is a randomized phase II clinical trial of the PROTECT DC intervention (hospital-based initiation of aggressive secondary prevention combined with navigator case management) vs. standard management in ischemic stroke patients from two underserved hospitals in the District of Columbia. The primary aims are 1) to refine the PROTECT DC design in preparation for a phase INI trial and, 2) to assess the effect of the intervention on 4 medication goals as defined by normalization of objective measures of secondary risk factor control. Project 3, DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) is a longitudinal, MR imaging, prospective, observational, cohort study designed to evaluate the prevalence and significance by race/ethnicity of chronic cerebral microbleeds in patients with primary intracerebral hemorrhage. Three cores will support the projects: A) Administration B) Participant Recruitment, Retention, Intervention and Outcomes, and C) Biostatistics / Data Management. This application is designed not only to define factors leading to racial/ethnic disparities in stroke treatment and outcomes, but also to demonstrate the efficacy of programs specifically designed to reduce these disparities.